HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to ensure the prevention and control of the spread of the COVID (Coronavirus)-19 infection within the hospital. This failure creates the potential that COVID-19 could be spread among staff, patients and visitors.

Findings include:

1. Upon arrival to the facility on 11/15/21 at 9:15 a.m., the state surveyor checked in at the front desk, as directed by signage, and was directed to proceed to the administration suite by volunteers working the desk. The state surveyor was not screened for COVID-19.

2. On 11/15/21 at 12:30 p.m., the state surveyor questioned a patient and his/her spouse who were sitting in the front lobby waiting area, if they had been screened for COVID-19 at any time when they entered the facility or thereafter. They stated they had entered the building through the Emergency Department (ED) and had not been screened at any time.

3. On 11/15/21 at 2:20 p.m., observation was conducted at the waiting room area of the ED with the Infection Preventionist (IP). Patients were noted sitting in chairs outside the waiting room and inside the waiting room. One (1) patient was noted to approach the registration desk and register for ED care. The process took approximately five (5) minutes.

4. On 11/15/21 at 2:30 p.m., an interview was conducted with the Registrar. The Registrar stated he/she did not screen the patient, who had just registered, for COVID-19 and stated it was not his/her job to do COVID-19 screening. The Registrar was unsure when COVID-19 screening was done for ED patients, stating, "Maybe by the triage nurse?"

5. On 11/15/21 at 2:35 p.m., an interview was conducted with a patient and his/her spouse who were sitting in the ED waiting room, if they had been screened for COVID-19 at any time when they entered the facility or thereafter. They stated they had not been screened at any time. They had been waiting in the ED since 12:00 p.m.

6. On 11/15/21 at 2:45 p.m., an interview was conducted with the IP. The IP acknowledged the patient who registered in the ED on 11/15/21 at 2:20 p.m. was not screened and stated the patients and surveyor should have been screened. However, the IP noted the volunteers had just returned to work and had not been doing screening before. When the state surveyor pointed out volunteer staff should be educated before being placed in a position where screening is to be done, the IP agreed.